Case Report: What—or who—killed Frank Ramsey? Some reflections on cause of death and the nature of medical reasoning

Philosopher Frank Ramsey died in 1930 aged only 26. There has been much speculation about the nature of his final illness and the sequence of events which led to his death. To prepare this case report, we traced Ramsey’s medical records and combined them with an extensive and unique dataset of contemporaneous sources. We use these to evaluate three possible explanations for Ramsey’s illness and its unexpectedly fatal trajectory—infectious (Weil’s disease), autoimmune (primary sclerosing cholangitis) and obstructive (gallstones). We explore how uncertainty surrounding each of these possibilities might have influenced Ramsey’s doctors’ thoughts and actions, including their ill-fated decision to perform the emergency operation that appears to have precipitated his final decline. We then reflect on the unfinished opus on which Ramsey was working when he died—on the nature of truth and how humans reason under conditions of uncertainty. We end with some thoughts linking Ramsey’s death to his philosophy.


Introduction
Frank Ramsey, a brilliant polymath and Fellow of King's College, Cambridge, died on January 19, 1930 in Guy's Hospital, London, at the age of 26.By that time, he had already made extraordinary contributions to three academic disciplines-mathematics (founding an important branch of combinatoric mathematics now called Ramsey Theory), economics (founding optimal utility theory, and publishing classic papers on optimal taxation and savings), and philosophy (while still a teenager, he translated Ludwig Wittgenstein's first book and published a far-reaching critique of it and he then made important contributions in the philosophy of language, the philosophy of science, and truth theory).As one Bloomsbury writer (Lytton Strachey) wrote to another (Dadie Rylands): "The loss to your generation is agonizing to think of -and the world will never know what has happened -what a light has gone out.I always thought there was something of Newton about him -the ease and majesty of the thought -the gentleness of the temperament" (Misak, 2020: 421).
Whilst it is known that Ramsey died after an acute illness characterized by several weeks of jaundice, the exact cause of his death remains a mystery.In this paper, we try to piece together Ramsey's final illness trajectory, speculating on the differential diagnosis and the proximal cause of death, using biographical archival material and recently unearthed (though tantalizingly incomplete) hospital case notes.Our research question was: "what-or who-killed Frank Ramsey, and what can we learn from studying his final illness about medical decisionmaking then and now?".This exercise in itself may shed some useful light on modes of medical reasoning but also illustrates the enduring relevance of Ramsey's thought to disciplines such as medicine.At the time of his death, Ramsey was working on a book about how we reason under conditions of uncertainty-an unfinished magnum opus which was drawing together interdisciplinary insights from philosophy, psychology, economics, and mathematics.Ramsey's thoughts on scientific hypotheses, subjective probabilities, and the nature of truth resonated for the authors as we grappled with provisional initial diagnoses and competing explanations for the ultimate cause of Ramsey's death.We end with some thoughts linking the philosopher's death to his philosophy.

Approach
We sought to undertake an interdisciplinary analysis, informed by clinical, historical and philosophical insights, of Ramsey's final illness.This aimed to build on preliminary discussions held among three of the authors (CM, MT and DN) in 2019.They, along with TG and GF, represented a range of sub-disciplines and had come together through their academic networks.We collaborated over a period of four months (July-October 2021) by email and video conference to develop and enrich an account of events and possible underlying explanations.GM, a professor of liver medicine, presented Ramsey's 'case' in a weekly multidisciplinary team meeting of liver clinicians.Provisional diagnoses were explored both through targeted searches of the contemporary literature and also using medical articles and books that had been available in 1930, so as to gauge how the clinicians of the day might have reasoned.As described below, we also consulted specialists in one rare disease.
The following sources had previously been collected by CM as part of a wider dataset to inform a book-length biography of Ramsey (Misak, 2020): -Letters from Ramsey's wife Lettice Ramsey to Ludwig Wittgenstein, letters from Ramsey to his wife, and other archival materials -Conversation with Lionel Penrose's son Roger, 2019 To this collection, TG sought and found the surviving elements of Ramsey's medical records from Guy's Hospital, London, which were sourced from London Metropolitan Archives in July 2021 using their professional searching service (see acknowledgements).Archivists looked for, but did not find, a coroner's report.
Whilst the original aim of the study was to pin down the cause of death, it became increasingly evident that each candidate diagnosis had some arguments in favour but also some arguments against.The study thus evolved into a contemplation on the nature of uncertainty and the sometimes fruitless search for truth.Given that Ramsey himself had written on this very topic, we went on to consider how his own (unfinished) writings might provide relevant insights.
The patient himself is, of course, long deceased, but we contacted surviving members of Ramsey's family, notably his grandson Stephen Burch, and received his permission to undertake the study and to reproduce a chart from the case notes.

Case history
In this section, we summarise what is known of the case.Ramsey was transferred from his home in Cambridge to Guy's Hospital on 10 January 1930 for investigation and management of worsening jaundice.His medical history was essentially unremarkable.He had neonatal jaundice and ill-defined "digestive" issues as a child.But by adolescence, he was a competent athlete and as an adult appeared to enjoy good health.He was a tall man tending towards weight gain-in his early 20's, he weighed nearly 17 stone: 240 lbs/108 kilos.Assuming his height was around 6 feet 4 (1.93 metres), his body mass index was about 29: overweight but not obese.He was physically active, including vigorous hiking and wild swimming.He was described as having "tremendous vitality".He was a member of the Bloomsbury set-a group of intellectuals and artists who lived life to the full and were known to have open marriages, as did Ramsey and his wife, the former Lettice Cautley Baker, who became a renowned photographer.While Lettice had multiple sexual partners, Ramsey appears to have had only one other: Elizabeth Denby, a senior civil servant and social housing reformer.
In mid-November 1929 Ramsey developed an acute febrile illness after a College feast (a formal occasion involving many courses of rich food, washed down with much alcohol).Nobody else attending the feast is known to have become ill, and there seem to have been no sick contacts, though Lettice developed a brief febrile illness in late November from which she recovered uneventfully.Within 10 days of the onset of fever, Ramsey developed jaundice with malaise, but no abdominal pain and no signs of bleeding or bruising.Progressive jaundice and malaise persisted for over six weeks.His cognitive status remained more or less normal throughout this period (no suggestion of encephalopathy), though he sent notes apologising to academic colleagues that he was unable to focus on his work.
On January 10, 1930 Lettice contacted her uncle, Robert Davies-Colley, a senior surgeon at Guy's Hospital, who arranged for Ramsey's admission.He was evaluated by a physician and a surgeon who apparently concurred on proceeding with a laparotomy to evaluate for biliary stones or other treatable cause of obstruction.Lettice wrote to Wittgenstein with an account of her understanding on Wednesday, January 15: Frank was operated on Saturday afternoon, because, after 8 weeks in bed he showed no improvement.My uncle, who's a surgeon, came from London to see him and thought that he should be brought to London to Guy's hospital.So we took an ambulance & came.Then there was a consultation with a physician (as opposed to a surgeon) & firstly they agreed that an op would be best.They found his gall bladder very inflamed & are draining it.There was no stone.I have seen Frank twice today, for a few moments.He is still too much under the effect of drugs to like any company . . .The dose of morphia that is always given after an op had a bad effect on him & he had to have something to counteract it.(Misak, 2020: 418) The above quote contains what appears to be an error by Lettice, since the actual date of the operation was Tuesday 14 th ; Ramsey died on Sunday 19 th .While the surgery did not reveal an obstruction, "the whole liver and kidneys were found in a frightful condition".(Misak, 2020: 425) The records suggest that a partial autopsy ("P.M. Examination of the abdominal organs") was performed but no findings from this are available.The death certificate simply read: Cause of Death: 1 (a) Cholangitis (b) Infection of smaller bile ducts 2 Hepatitis.

P.M. Examination of abdominal organs
Lettice said that Frank "died of an infected liver".Davies-Colley told Ramsey's father it was "a degenerative disease of the liver which was bound to end fatally".Lionel Penrose (father of British genetics and himself a medical doctor) was one of Ramsey's best friends, and apparently had a different view.
He would later allude to the possibility that medical malpractice was the cause of death and he was wracked with guilt about not having been around to step in and save his friend (Misak, 2020: 425).
In 2019, before the hospital case notes were unearthed, MT and DN (a medical intensivist and an internist, respectively) were helping CM (a philosopher) think through Ramsey's cause of death for her biography.MT made a surmise, based on the biographical materials and death certificate: Leptospirosis, particularly the severe form, Weil's disease, caught from swimming in the River Cam.MT's reasoning started with the observations that Ramsey had no antecedent medical problems to suggest a chronic illness and never developed encephalopathy (ruling out some common causes of acute liver failure).Supporting this speculation, the course of disease broadly fit the classical description of leptospirosis, a febrile illness followed by jaundice that typically involves both the liver and the kidneys.
Leptospirochetes have been isolated from samples taken from the Cam in recent years.The physicians and surgeons caring for Ramsey did not discover a firm alternative diagnosis despite a laparotomy and post-mortem examination.DN was sceptical, as he thought that the incubation period was such that Ramsey would have had to be swimming in the river in late October-a bit cold and hence unlikely.But it turned out that the weather in October 1929 was headline-worthy warm.DN concluded that the leptospirosis hypothesis was not unreasonable.CM's biography floated the surmise, saying also that the surgical procedure, when Ramsey was already very unwell and jaundiced, "undoubtedly hastened his death".(Misak, 2020: 425) TG had trained as a general practitioner and been taught the maxim that rare symptom combinations are more often caused by atypical presentations of common diseases than by rare diseases.She suggested in the spring of 2021 that we take a new look at Ramsey's cause of death, hypothesising that it might be explained by an unusual complication of acute viral hepatitis (which was very common at the time), rather than by leptospirosis (which was rare).We invited the opinion of a hepatologist (GF, a professor of liver medicine who edits the journal Viral Hepatitis).GF was even more sceptical about the leptospirosis hypothesis, as he felt the disease course was too slow, and the lack of encephalopathy unusual, as it meant that Ramsey did not have the acute liver failure that characterizes the fatal form of leptospirosis known as Weil's disease.
Following discussion among his multidisciplinary team, GF posited the autoimmune disorder primary sclerosing cholangitis.Supporting this diagnosis, the condition is commoner in men than women, can present in early adulthood, is caused by an inflammation and strictures of the bile ducts, and causes portal hypertension-a complication which carries a very high mortality if operated on.In this scenario, Ramsey's febrile illness following the College feast (perhaps suggesting an infectious process) was perhaps a red herring.Rather, the picture of a gradually worsening jaundice over several weeks followed by rapid deterioration (including tachycardia and severe anaemia requiring transfusion) after a laparotomy and death soon after pointed more towards a non-infectious hepatic disorder that was made fatal by surgical intervention.This, however, does not fully explain why Ramsey's kidneys, viewed per-operatively, as well as his liver, would have been in what his wife called "a frightful condition".Nor does it fit well with the reports of Ramsey's robust health and absence of typical symptoms prior to his acute illness, as primary sclerosing cholangitis generally has a more indolent course with prior episodes of obstructive jaundice.
In short, the narrative history accommodated multiple potential diagnoses, though none without having to acknowledge some inconsistencies.

Clinical information: Elucidating? Confounding?
Archivists at Guy's hospital supplied us with a photocopy of the surviving parts of Ramsey's hospital record, providing further (though incomplete) details of the case.The Case Notes (completed by the Registrar of Deaths), which were not made available to CM during the writing of her biography, include the following entry: Nature of Case: Inflammation.Chronic spirochaetae.

Liver. Hepatitis
Result: Laparotomy-Death The Notes tell us that upon admission to Guy's, Frank Ramsey was jaundiced, afebrile, with a heart rate of 80 and respiratory rate of 20 per minute (Figure 1).Blood tests on admission showed a normal white blood cell count and differential.Bleeding time was reported as normal (using the technician's blood as the control).There was no haemoglobin level reported on admission, and red cell morphology was described as "slight anisocytosis and a few (halo) cells".Blood culture was negative, and a Wasserman test for syphilis was also negative.His urine (tested the day after admission) contained bile, which confirms the diagnosis of jaundice without adding further diagnostic information.No calculus was noted on a plain radiograph.Since most gallstones are radiolucent, this negative finding did not exclude that diagnosis.Ramsey was taken to the operating theatre on Day 5.
As the chart shows, Ramsey remained afebrile and hemodynamically stable until the laparotomy.There is no operative note available, but in the immediate post-operative period his pulse rose from a steady 80 to between 110 and 130 beats per minute, though he remained afebrile.Haemoglobin was reported at 58% on January 17 and there is reference to a transfusion that afternoon and a second transfusion the day after.
Haemoglobin even in the 1920s was commonly expressed as gm per 100 cc (or per dl in current shorthand) after conversion from percentages derived from colorimetric scales.However, normal ranges were well known with colorimetric methods, and it seems likely that this result was derived from Haldane's popular hemoglobinometer scale (Haldane, 1901).
If so, on that scale 100% was the normal for young healthy men, corresponding to 13.8g/dl and 58% would represent profound anaemia consistent with acute blood loss.
The clinical notes confirm an impression that Ramsey's condition had become unstable that morning.At 10.55 that day, Ramsey got "Pituitrin", which is a combination of oxytocin and vasopressin-seemingly the best inotrope available at the time and suggesting that his blood pressure might have been falling precipitously.He also received "anti-gas gangrene serum", perhaps as the nearest thing available at the time to broad-spectrum antibiotic cover.All this suggests concerns about both post-operative blood loss and sepsis.
At 6 pm on January 18 th , Day 9 of the admission, a bedside procedure was performed with "gas and oxygen" (the gas was presumably nitrous oxide or ether) and "local infiltration" was performed with procaine borate, a local anaesthetic developed in the UK and introduced into practice in the mid-1920s.
A jejunostomy was then performed, but we have no further information about the procedure or why it was deemed indicated.The treatment record shows, however, that after the operation, Ramsey received a single dose each of atropine, strychnine and adrenaline.The events of these days, charted telegraphically and dispassionately in Ramsey's clinical record, leave the modern reader with no doubt that Ramsey was in dire straits.
Ongoing nursing notes record that his respiratory status worsened.After his bedside operation he was troubled by persistent hiccups (which can occur following abdominal surgery), and had a brief period of delirium preceding his death on Day 10 of the admission.
Our review of these medical records prompted a re-examination of the provisional differential diagnoses on which we had originally speculated.The notation referencing spirochetes initially appeared to support the surmise of leptospirosis.While "chronic spirochaetae" or "spirochaetosis" was generally used to describe yaws or syphilis, by 1915 it was known that a spirochaetae (spiral-shaped bacterium) was the cause of Weil's disease (Alston & Brown, 1937: 743).Ramsey could not have had yaws, since this infection is acquired during childhood through skin contact in remote regions of Africa, South Asia, and the Western Pacific islands.The Wasserman test for syphilis, widely believed to be highly accurate, was negative.The specific mention of spirochetes in Ramsey's record kept leptospirosis (or Weil's disease or Spirochaetosis ictero-haemorrhagica) high on our list of possibilities-but it fell short of proving that this was the cause of death.
Our team now included four doctors, one of whom was a hepatologist, but the clinical picture remained confusing.Two leptospirosis experts, Dr. Albert Ko and Dr.Joseph Vinetz, kindly agreed to review the case.Both discounted the diagnosis of Weil's disease, usually defined as the triad of jaundice, bleeding and acute renal failure, given the sub-acute course of Ramsey's illness.Death from Weil's disease typically occurs within 2-3 weeks after onset of symptoms, while Ramsey had a prolonged course of illness and jaundice over six weeks, and the death is typically caused by acute renal failure, hemorrhage or other severe manifestations (myocarditis, arrhythmias, vasculitis, stoke, etc), of which there was no evidence.As for the notation regarding spirochetes, both Drs.Ko and Vinetz commented that the description of spirochetes on dark-field microscopy at the time often represented a false positive.In sum, contemporary experts in leptospirosis placed little value on the new piece of evidence ("spirochetae") because the disease course did not fit the overall pattern and time-course they would have expected-an example of how expert clinical knowledge is built by accumulating and refining 'illness scripts' (internalised narratives of how a disease unfolds) (Schmidt & Rikers, 2007).
An alternative approach to the differential diagnosis of Ramsey's illness starts with the fact that his physicians and surgeons never arrived at a definitive diagnosis, suggesting they could have been dealing an entity with which they were unfamiliar.
Neither leptospirosis nor primary sclerosing cholangitis appear to have been prominent in the thoughts of clinicians of the day and there is some evidence that these conditions were sometimes missed.
Diseases caused by Leptospira bacteria, for example, were not very well-recognized in England at the time of Ramsey's illness and hospitalization at the turn of 1929-30.The organism had been isolated for the first time in that country in 1922; in 1924 there had been an outbreak in East Lothian coalminers.Alston & Brown (1937) described the epidemiology of Weil's disease and bemoaned the fact that there were very few papers about it in the 1920s, with interest sparked in the disease only in 1934 when it was shown that infection occurred among sewer workers in London.It was by then known to be carried by rats and their urine, with cases arising also in "field-work… fish-cleaning and bathing in fresh water" (1937: 741).Only in 1935 was there an effort to authenticate British cases and to try to estimate the proportion of cases of jaundice that were leptospirosis and how many asymptomatic cases there were.Alston and Brown concluded that "It is probable … that the disease is much more prevalent than our present records testify" and that "infection may produce disease of different degrees of seriousness or no observable disturbance of health."(1937: 3-4) Diagnosis of any spirochetal infection before the advent of serology was also difficult.It depended on silver stains or appearance under light microscopy-one species of spirochete could not be reliably distinguished from another by that method.The notation of "chronic spirochaetae" in Ramsey's medical record indicates a microscopic finding, perhaps from urine or from samples taken during the laparotomy, but there is no evidence that his physicians connected this finding to his illness.
Similarly, while primary sclerosing cholangitis appears to have first been described in Germany in the mid-1800's, the condition featured mostly in scattered case reports and was poorly characterized for the next century (Eaton et al., 2013).At the time of Ramsey's illness, surgeons recognized that biliary strictures could develop post-operatively (usually after cholecystectomy) or in association with gallstones, but reports of diffuse generalized involvement of the extrahepatic biliary ducts not associated with surgery or stones were rare.The first well documented case in the English language appeared in 1927 (Miller, 1927), with only around two dozen additional reports of spontaneously arising extrahepatic strictures being described over the next 40 years (Warren et al., 1966), and in the pre-electronic era, most clinicians would not have had access to these.Until more sophisticated imaging of the biliary tree became possible in the 1960s and 1970s with adoption of endoscopic retrograde cholangiography, the disease was generally not distinguished from far more common causes of biliary strictures in surgical case series and reviews.Lacking an operative note, we cannot say what the surgeon saw when inspecting Ramsey's biliary tree, other than the absence of stones.But as with leptospirosis, primary sclerosing cholangitis as a potential diagnosis was very unlikely to be on the differential diagnosis docket for a physician or a surgeon in 1930, and might therefore explain both the decision to proceed with a laparotomy and the lack of clarity then and now about the cause of Ramsey's initial illness and subsequent death.
Indeed, no single diagnosis considered by our group of co-authors seems to fit completely with what is known of Ramsey's illness trajectory, the findings described by his family and doctors, and the fact of his death.The course was not fulminant enough for Weil's disease and while the more common and milder form of leptospirosis certainly fit with the initial presentation, this form is typically self-limiting and short-lived.Primary sclerosing cholangitis readily explains painless jaundice in the absence of acute liver failure, but the lack of associated and antecedent symptoms would be atypical and the course of illness generally plays out over years, not weeks.Other causes of acute obstructive jaundice, benign, infectious, and malignant, would fit, but tend to be extremely rare in young people and would also have gone unrecognized by Ramsey's doctors.Even an unusually prolonged course of hepatitis A could explain Ramsey's course up until his surgery, but it would not fit with descriptions of his internal organs.Once a diagnosis does not provide a unifying explanation for all of the "facts" of a case, a wide variety of diagnoses can, with varying degrees of plausibility, be made to fit.
One of the most important features of medical diagnosis is how the illness progresses over time.In Ramsey's case, had his medical team been able to watch the illness play out, it would likely have aided them in making a diagnosis.Leptospirosis would have resolved, as very likely would hepatitis A.
Primary sclerosing cholangitis would have grumbled along, perhaps taking years to progress to end-stage liver disease.But as fate would have it, the natural history of Ramsey's disease was interrupted by a well-intentioned surgeon seeking a remediable cause of persistent jaundice.

Reflections on the clinical reasoning
The history alone raised some questions about the decision to operate on Ramsey.After viewing the case notes, the chart of Ramsey's vital signs (Figure 1), and particularly the events of January 17 th and 18 th 1930, it seems even clearer that the surgery was the proximal cause of his demise.If his illness was due to a mild form of leptospirosis or prolonged viral hepatitis, Ramsey's prognosis without the procedure would have been good.Even primary sclerosing cholangitis and other non-malignant causes of obstruction would have been expected to have a reasonable short-term prognosis without surgical intervention, though the former would have ultimately proved fatal in an era before liver transplantation.
However, it cannot be straightforwardly asserted that the decision (made by a combined medical and surgical team) to operate was an error of judgment.Using only the evidence available to them at the time-a clinical suspicion of gallstones, an unwell and non-improving patient, a negative test for a key competing diagnosis (syphilis), and little else in their armamentarium-Ramsey's doctors may have reasoned that the risk of precipitating a decompensation was more than balanced by the chance of finding and rectifying a treatable cause for the illness.Whilst there is little doubt with hindsight that the surgical procedure precipitated Ramsey's death, it is much harder to judge whether the decision to operate was a reasonable one at the time.
These days, surgeons in training are taught to weigh up the pros and cons of every operation and discuss these with patients before obtaining written informed consent to proceed.This is partly because a great deal of research since Ramsey's day has demonstrated that many conditions which used to be routinely treated surgically (for example, recurrent tonsillitis, some kinds of coronary artery occlusion, menorrhagia, and even some presentations of appendicitis) have an equal or better prognosis if managed without a surgical procedure.Although back in 1930, medical and minimally invasive alternatives to major surgery were far fewer and surgeons' confidence in their ability to improve the patient's outlook was perhaps somewhat stronger than it is now, the fact that Davies-Colley consulted with a medical colleague to deliberate on whether to operate or not suggest that the pros and cons were being weighed very carefully.Unfortunately, the notes do not offer any delineation of the clinical reasoning for the decision to operate, and we are left to fill in the blanks.
The challenge faced by Ramsey's physicians and surgeons is plain: they were faced with a patient with an illness they could not quite explain, could not definitively diagnose, but which appeared unremitting.Under such circumstances, a reasonable clinician would be bound to ask: what could we be missing that might be reversible?Two questions are pertinent here-how serious the condition is and how likely it is to be present in this particular case?A potentially reversible cause of death becomes impossible to ignore, even if it remains low on our list of differential diagnoses, and particularly if the trajectory of the patient is perceived to be steadily downhill.In Ramsey's case, the most salient reversible condition was choledocholithiasis, an impaction of a stone in the common bile duct.Some features of the illness pointed away from this, such as the apparent lack of abdominal pain, but again Ramsey's illness did not fit well with any available alternative diagnosis.
In an era where additional diagnostic tools, such as ultrasound, endoscopy and contrast-enhanced CT scanning did not exist, no active alternatives to surgery were available.
Davies-Colley and his colleagues were likely influenced by a strong psychological compunction to do something for their patient rather than manage him expectantly.This bias toward intervention continues to permeate medical and surgical practice (Foy & Filippone, 2013).To not operate would have required them to watch a previously vital and brilliant young man become increasingly jaundiced and -they may have assumed -eventually die.A decision not to operate, only to later discover a stone on a subsequent post-mortem examination would have weighed heavily on the mind.So given the possibility that a non-calcified stone sat wedged in the common bile duct, they chose to operate.
Another influence on the psychological compunction to do something (i.e.operate) is the extent to which doctors of the day might have underestimated the possible adverse effects of surgery.They clearly thought that surgery might improve the patient significantly (a positive impact of surgery), and they must have contemplated the possibility that they may not find a stone (neutral impact of surgery), but perhaps they did not fully factor in the possibility that surgery would have a severely negative impact on the patient's trajectory.Put another way, Ramsey's doctors would not have ignored the risks of operating, but, in the face of uncertain evidence and with the wisdom of retrospection, they misjudged them.One can only imagine the disappointment and resignation, but not surprise, when no stone was found-and how the resignation turned to dismay when the patient's post-operative course turned stormy.

Ramsey on counterfactuals and scientific hypotheses
We have employed counterfactual reasoning in re-examining Ramsey's cause of death-reasoning of this sort: If the diagnosis had been leptospirosis, viral hepatitis, or some benign causes of obstruction and if the laparotomy had not been performed, then Ramsey would have been expected to survive his illness.Some might think these spurious kinds of post-hoc reasoning.But Ramsey himself gave us a way of understanding the rationality of counterfactual conditionals.He suggested that we can evaluate a conditional 'if p had been the case, then q would have been the case.'What is now known as the Ramsey Test for Conditionals is a method for determining whether we should believe a such conditional.We add p, hypothetically, to our given body of belief.If the acceptance of p leads to a contradiction within that body of belief, we make adjustments, as minor as possible, in order to restore consistency.Then we ask whether q is acceptable in the revised body of belief.On this test, 'Ramsey would have survived his illness if he hadn't been operated on' does indeed seem acceptable.
There are other philosophical issues with the clinical reasoning in our review that would have interested Ramsey the philosopher.How did the clinical understanding of this patient's illness evolve as his doctors assessed him, took measurements, sent tests, and contemplated what was the most likely diagnosis?How did that partial and evolving understanding influence the key clinical decisions and actions which likely contributed to his untimely death?
The link here is to Ramsey's position as a self-declared philosophical pragmatist-a philosopher who starts not with the quest for certainty, but with what he called a "human logic" (1926 (1990): 87).For instance, when he was an undergraduate, he challenged one of his eminent mentors, the great economist J.M Keynes, on the nature of probability and induction.
In his Treatise on Probability (1921) Keynes had argued that there is one true probability holding between any two propositions-an objective relation about a degree of partial entailment, part of the formal machinery of drawing conclusions from premises.The young Ramsey argued that there are no objectively fixed probability relations-propositions do not stand in such logical relations to each other.As he put it, there is no such probability as the probability that 'my carpet is blue' given that 'Napoleon was a great general' (Ramsey, 1922: 220).Ramsey argued that reasonableness is a matter of having beliefs or habits that work well.Induction is justified not because it is objectively valid, but because it is an indispensable habit, leading, on the whole, to success when we act.
Later, in his 1926 paper "Truth and Probability" (Ramsey, 1926), he offered an account of how to measure partial belief by using a subjective interpretation of probability.Degrees of belief can be measured and assessed by examining the disciplined connection between the inner states of beliefs and desires, on the one hand, and the outer states of behaviour, action, and success, on the other.Beliefs are bets that play out in action in the world, and can be evaluated in terms of their success.This paper became a classic, as it was the first time someone had provided a measure and logic of partial belief, as well as a model of subjective expected utility.
Ramsey's foundational work on partial belief underpins elements of contemporary economics, Bayesian statistics, evidence-based medicine, and much else.
Ramsey, however, was sceptical about applying this highly idealized model to the real world.For one thing, we have imperfect evidence for our beliefs.For another, we can't measure degrees of belief with precision.Hence no human can live up to the standard of keeping their degrees of belief consistent with the mathematics governing probability.An ideal agent, having full or certain beliefs about every single thing, might always act in a way that she would expect to maximize utility.But people are far from ideal: …the ideally best thing is that we should have beliefs of degree 1 in all true propositions and beliefs of degree 0 in all false propositions.But this is too high a standard to expect of mortal men, and we must agree that some degree of doubt or even of error may be humanly speaking justified.(1926 [1990]: 80) Moreover, human fallibility, in Ramsey's view, is not a friction that interferes with the smooth working of decisionmaking, but is the condition of humankind.Human psychology cannot be theorized away, as individuals will make different initial probability assignments, and strength of belief will vary from person to person, in ways partly driven by their psychological traits.
Ramsey's notion of human logic, which begins with subjective belief and seeks progressively to refine this belief through experience, experimentation and measurement, reflects with remarkable accuracy how clinical reasoning progresses-both traditionally and in contemporary times.Traditionally, we would begin by evaluating a presenting complaint, usually in the form of a story fragment ('he went to a feast, and soon afterwards, he developed a fever and then his skin then turned yellow').
We would wonder, 'what could this be?'-perhaps formulating a preliminary list of differential diagnoses, each of which we believe to be more or less likely ('prior probabilities').We would ask questions ('how did you feel before the feast?', 'were you a vigorous child?', 'how are your bowels?'), examine the patient (is there a palpable liver edge and is it tender?), and conduct tests from a limited list of options (e.g.plain X-ray, urine for bile), thereby progressively adjusting our subjective beliefs about each differential diagnosis ('posterior probabilities').To aid this process, we would draw on our internalised scripts of illness trajectories (the sum total of all the stories of patients with similar or contrasting conditions we had ever managed or seen managed or heard about from colleagues), and applied maxims-that is, shared rules of thumb-which encode risky scripts, such as 'never let the sun set on a blocked common bile duct' (because, presumably, many such patients died overnight).Maxims are situationallyspecific, and can often be contrasted with counter-maxims that apply in subtly different circumstances-for example, "people who do not need operations rarely improve after having them".Clinical wisdom is more about selecting which maxim to follow than about rigidly adhering to a protocol or guideline (Hunter, 1996).
In contemporary times, broadly the same process is followedwith three key differences.First, we are taught to rely less on our subjective assessment (e.g. the liver edge we do or don't feel meeting our palpating fingers as the patient breathes in) and more on 'objective' information such as imaging and laboratory tests, which are both more numerous and more accurate than in Ramsey's time (witness the battery of modern invasive imaging tests today's clinicians would have offered Ramsey).Second, we are now encouraged to put numbers to our prior and posterior probabilities for a particular patient by using generalised probabilities generated in large randomised controlled trials and observational studies of patients judged to be compatible to our own (a patient in his 20s with deteriorating jaundice following a fever has an x% chance of Weil's disease and a y% chance of primary sclerosing cholangitis; (Jaeschke et al., 1994)) and to synthesise such data into clinical decision rules for guiding next steps (McGinn et al., 2000).Third, we are encouraged to quantify by how much a particular positive or negative test should increase or decrease our subjective belief in a particular diagnosis-the so-called likelihood ratio.Indeed, Ramsey would have approved of the contemporary fashion of drawing receiver operator characteristic (ROC) curves of likelihood ratios depending on the chosen cut-off value for distinguishing disease from health in continuously varying parameters (Søreide et al., 2011).He would not have been surprised that very few tests definitely rule in or rule out a diagnosis-they just make that diagnosis more or less likely depending on the observed result.
Ramsey would, perhaps, also have something to say about how much we should resist or succumb to our subjective hunches in this brave new world of high-tech imaging, clinical decision rules, likelihood ratios and ROC curves.The empirical Bayesian pretensions of many of today's clinicians often consist of more or less generalizable probabilities from the relevant literature (true for many images, lab tests, and RCT results) combined with subjective probabilities and partial beliefs gleaned from our own experience and interpretations of the history and physical findings.The decision-making process remains a potpourri of deductions, inductions, and abductions that gels into a clinical Gestalt. 1 And trying to explain Gestalt A versus Gestalt B is like trying to trace the outlines of one of those maddening duck-rabbit shadow-grams that Ramsey's friend Wittgenstein made famous -not least because, as all kinds of literature shows, the Gestalt is shaped by context and values (with specialty training and practice setting as factors that alter both).
In the year of his death, Ramsey wrote a flurry of papers that started to carve out a view of scientific laws, theoretical terms, and causal statements that went against the prevailing objectivist winds.We should not "take the propositions we make in science and everyday life, and try to exhibit them in a logical system with primitive terms and definitions" (Ramsey, 1929a: 7).Here, he was referring to what the logical positivists (inspired by Wittgenstein) were doing in 1929: trying to build all knowledge on a foundation of certainty.In contrast, Ramsey argued that we have to see "the vagueness of the whole idea of understanding, the reference it involves to a multitude of performances any of which may fail and require to be restored" (Ramsey, 1929a: 2).We "are forced to look not only at the objects which we are talking about, but at our own mental states.… we cannot neglect the epistemic or subjective side" (1929a: 6-7).Scientific and causal laws are habits or rules with which we meet the future (Ramsey, 1929b(Ramsey, : 1990: 149): 149).With all the generalised probabilities available to us in the entire medical literature, we five co-authors still needed to consult experts in leptospirosis to make sense of what the history and test results meant in Ramsey's case.All the clinical decision rules in the world cannot substitute for the subjective component of clinical expertise and wisdom.It is also generally true that physicians should not play their hunches as a substitute for following the algorithm.Hence the delicate balancing act that characterises (or should characterise) evidence-based-medicine.
For their part, Ramsey's medical team struggled to find a unifying Gestalt for the disparate information in their possession.They clearly thought syphilis a possibility, perhaps because of its prevalence, perhaps because Davies-Colley knew his niece and her husband were part of Bloomsbury's swinging sexual scene.They ruled that out with the Wasserman test and turned to alternatives they could act on-with surgical procedures.Those procedures ruled out the further hypothesis of the blockage.
When the time came to list official causes of death, it appears the case was forced to fit within the taxonomy of disease available to them at the time-an early version of the International Classification of Diseases (Bowker, 1996), even though Ramsey's clinicians were unable to definitively give a name to what it was that ailed him.
Ramsey would likely have cautioned us regarding our initial quest to diagnose his pre-terminal illness, and would not have been at all surprised by its indeterminate outcome.It is unlikely that we or our successors will arrive at a definitive truth about the question: what was the illness that led to Ramsey's death?But such a definitive truth was something about which Ramsey gave us reasons to be suspicious.Our conclusion will always be underdetermined by the data, and the data we have will almost always accommodate more than one theory.A conclusion will be probabilistic and the only way we can evaluate it is in terms of its being a rule that meets the future well.Ramsey's medical team met the course of his disease progress with rules that failed them and their patient.But they, like us, were making decisions on the basis of partial belief, the available evidence, and the current theories.
From beyond the grave, Ramsey tells us to not be in thrall to the current theory, to understand that our degrees of belief are only as good as the evidence (both subjective and objective) that informs them, and that our decisions are freighted with psychology and our ongoing theories.
The quest for certainty in clinical medicine, Ramsey tells us, is a fool's errand.Patients and clinicians alike would do well to remember the uncertainty that must permeate medicine.And clinicians, in particular, would do well to improve upon those aspects of clinical reasoning that incorporate probabilities and belief, rather than searching for definitive algorithms or defaulting to rules that are poorly applicable to the case at hand.

Response to commentaries
We thank all four reviewers for their engagement with our paper and their insightful comments.All 'approved' the paper and couched their reviews as commentaries rather than critiques, but all contributed important insights which take the discussion of Ramsey's untimely death into new territory, which we explore in this new section of our paper.
John Gabbay, a retired public health doctor and medical historian, observes that concepts of disease are social constructs and that historical diagnoses and management plans are made using "different theoretical lenses, different norms of practice, different available diagnostic resources and different treatment choices" to the ones we'd use today.Even the most rigorous efforts to get inside the intellectual and practical world of yesterday's clinicians are usually doomed to failure (though in this case, he congratulates us on our partial success).He challenges us on our over-rational depiction of modern-day clinical reasoning based on prior probabilities and algorithmic decision-making and suggests that the more intuitive (and fuzzy) 'clinical mindlines' might better explain most clinicians' reasoning, most of the time (Gabbay & le May, 2016).
We agree with his approach.One of our central points, which is useful to re-iterate in Gabbay's language, is that our medical concepts and methodologies are always changing and evolving (we hope for the better).This is a pillar of the pragmatism Ramsey promoted, which takes all our concepts to be revisable, with ripple effects throughout of our body of belief.This state is inescapable-we cannot identify Archimedean touchstones that serve as the infallible foundation for knowledge.But what we can and must do is come to the best conclusion we can, given current definitions and assumptions.That conclusion is of course itself open to revision.It is in that pragmatist spirit we have explained and evaluated the reasoning around Ramsey's death.
Prior to writing her review, academic nurse Kathryn Jack read several nursing textbooks that would have been available to her predecessors in 1930, immersing herself in the theories and professional norms of the day and igniting her historicallysensitised clinical imagination.She is able to explain why there was no blood pressure chart in amongst Ramsey's records: nurses of the day were expected to estimate the blood pressure from the quality of the pulse ("bounding" or "thready", for example)-a method now known to be unreliable.In another important insight, Prof Jack comments that "Nursing care, then and now, places strong emphasis on the importance of maintaining asepsis and cleanliness, but sterility standards were not as they are today."She points out various procedures that posed substantial risk of sepsis-including blood transfusion, which in those days would have been undertaken crudely by syringing blood directly from a donor and injecting it into the patient, repeatedly in 20cc aliquots (Ashdown, 1929).Whilst Ramsey was noted to be apyrexial in the days before his death, Prof Jack makes the very reasonable suggestion that he may have developed "cold" sepsis (that is, overwhelming infection without fever).
A re-analysis of Ramsey's record affords some support for this suggestion.Post-operatively, his condition worsened quickly.
As we noted in our original article, Ramsey's physicians were concerned about both bleeding and sepsis, responding with two transfusions and anti-gas gangrene serum (the standard treatment for severe infection in the pre-antibiotic era).We agree that the two most likely contributors to his decompensation and death are anemia and sepsis.The former was most likely due to acute blood loss during surgery, but if anaemia secondary to acute blood loss was the sole problem, his raised heart rate would probably have responded to a transfusion.He was, therefore, highly likely to have been septic.Fever is not part of the (current) definition of sepsis because a significant proportion of septic patients never mount a fever-and those patients have a worse prognosis (Rumbus et al., 2017).It is unfortunate that blood pressure was not routinely measured during this era, as hypotension would have lent weight to the diagnosis of sepsis.One possible additional diagnosis could be disseminated intravascular coagulation (DIC) as a consequence of surgery and/or post-operative sepsis.This could have contributed to the anaemia and to the overall decompensation and rapid decline.Unfortunately, platelet count, bleeding time and blood smear do not appear to have been repeated after surgery (they were essentially normal prior to it), so we have no direct evidence to support or challenge that potential complication.
In sum, we agree with Prof Jack that sepsis was likely and that some combination of blood loss, sepsis and DIC were likely causes of Ramsey's catastrophic decline.Again, we find support for Ramsey's pragmatism.Rarely does an event have a straightforward single-track cause.While 'multi-factorial' may a useful refuge for medics when they are diagnostically destitute, it is better thought of as the right conclusion when we are in the common state of being causally overburdened.
The cause of the original liver condition, however, remains unsolved.Prof Jack ventures another suggestion for this: polycystic disease, which can affect both liver and kidneys and may explain why both sets of Ramsey's organs were described to be "in a frightful state" by his wife.We discussed this possibility but were not convinced that the surgeons would have described a polycystic liver or kidney in this way.The macroscopic appearance is unmistakeable (the organs are huge and full of obvious cysts) and, since it is relatively common, anyone who had spent any time in the postmortem room (a standard part of medical training throughout the 20 th century) would be familiar with their appearance.
Mathew Mercuri, a philosopher and epidemiologist, raises the question of clinical responsibility.Reflecting on this case through a modern-day lens of medical malpractice, he asks, "would it be fair to say the surgeon is responsible for Ramsey's death (which is different than saying the surgery is the cause of his death)?".Ramsey's illness and death pre-dated the landmark 1957 'Bolam case' (Bolam v Friern Hospital Management Committee, 1957) which decided English tort law on this question and remains the only legal case that almost every graduate of a UK medical school can recount.Its conclusion-that if a doctor reaches the standard of a responsible body of medical opinion, they are not negligentsuggests that even if the operation caused (or hastened) Ramsey's death, the man who wielded the scalpel was not responsible, since a reasonable surgeon in the same circumstances may have made the same decision.
Of course, legal principles, precedent and conceptions of responsibility, as Oliver Wendell Holmes Jr. put it, are also are human constructs which evolve in responsive to experience: "The life of the law has not been logic: it has been experience.
The felt necessities of the time, the prevalent moral and political theories, intuitions of public policy, avowed or unconscious, even the prejudices which judges share with their fellow-men, have had a good deal more to do than the syllogism in determining the rules by which men should be governed.The law embodies the story of a nation's development through many centuries, and it cannot be dealt with as if it contained only the axioms and corollaries of a book of mathematics."(Holmes, 1882).Holmes was one of the founders of the philosophical tradition of pragmatism in 1867.What he says about the law applies also to medicine.
More recently, the 2015 legal case of Mrs Montgomery (a small woman whose large baby was birth-damaged after clinicians failed to warn her that it might get stuck if she delivered vaginally) in Scotland made clear that clinicians have a duty to warn their patients of 'material risks' of surgical and other interventional procedures (Montgomery v Lanarkshire Health Board, 2015).This ruling was criticised in a provocative paper co-authored by two more Montgomerys (a law professor specialising in consent and an academic midwife, no relation to the plaintiff but married to one another) who declared the ruling ethically facile, clinically impractical and based on "infantilising the patient" and "demonizing the doctor" (Montgomery & Montgomery, 2016).Nevertheless, these days Ramsey would certainly have been warned that deterioration and death were a possible outcome of the proffered operation.Since this seemed the best course of action, given the current state of information, Ramsey the pragmatist would probably have signed off on the procedure.
Prof Mercuri, like Prof Gabbay, is interested in the nature of clinical decision-making.He asks whether the clinicians caring for Ramsey were reasoning algorithmically or more intuitively."Was it their algorithms that let them down", he asks, "or was it that they did not pay enough attention to them?".While 'algorithm' was not part of the medical lexicon in the early 1930s, Ramsey's clinicians likely relied on heuristics, informal rules of thumb derived from direct experience and passed down to trainees, often as dogma.Ramsey's doctors understood that, mechanistically, jaundice is often caused by an anatomical obstruction of biliary drainage.Perhaps such an obstruction could be removed.In the end, the decision that sealed Ramsey's fate may have rested on a fundamental heuristic of the surgeon: a chance to cut is a chance to cure.
John Capps, a philosopher who specializes in pragmatism, asks an excellent question about our claim that that definitive truths are out of reach-whether our emphasis is on 'definitive' (we can never know for sure) or 'truth' (there is no such thing).Ramsey's case is particularly marked by the kind of uncertainty he studied-conflicting evidence, multi-factorial causes, decision-making under conditions of great uncertainty.
That supports the 'we can never know for sure' idea.With respect to truth, the pragmatism of Ramsey's sort (and the sort we adopt in our paper) holds that we can indeed discover truths, even as those truths are human truths, not something handed down by God or Logic.
Consider Aretha Franklin, the US singer commonly called 'the Queen of Soul' who died in 2018.Her doctors staked their reputations on the conclusion that she died of pancreatic cancer.They did so based on multiple lines of strong evidence, and we accept their conclusion as true, even though medicine still has no definitive account of the mechanism of cancer death in the absence of destruction of vital structures -and despite the fact that our concepts and language around cancer will inevitably evolve and change.Knowledge undergoes revision, but some things will remain stable while being responsive to new evidence and concepts.It is the remaining stable or standing up to all evidence, argument, and future revision that constitutes a truth.That is why we should say 'we wager we know that Aretha Franklin died of pancreatic cancer' -we cannot know what we will know, when all the textbooks are finally rewritten, as it were.Capps is right to say that we care about the truth, and we hope to achieve it, even if it is often not within our reach.
Jack observes that "There is a growing appetite amongst healthcare researchers … to conduct mixed methods research underpinned by pragmatism."We hope to have contributed to the theorizing of that pragmatist project in our paper and this addendum to it.
I'd like to thank the authors and editors for this opportunity to review such an intriguing casestudy that is woven into Frank Ramsey's, (the patient), philosophical teachings.However, more importantly I'd like to thank Stephen Burch for permitting this public scrutiny of his grandfather's illness and death.All case studies, however old, give clinicians the opportunity to reflect, learn, and consider how their own practice (be that clinical, education, research, or any combination) could be improved.I'm not a philosopher, but an academic nurse, so my review is focused through this lens.
In keeping with the style of reviewer number one, my review of this fascinating story is a short commentary.The manuscript meets all of the usual domains required for a case study with one possible exception, that being the limited clinical details reported.However, I am highly mindful of the need to protect Frank's confidentiality, and of the likely scant medical and nursing records that were both recorded in writing at that time and retained in medical notes.Therefore, I consulted historical textbooks (Ashdown, 1929;Morten and Taylor, 1942) to further illuminate the nursing and medical thinking at that time.
According to the available records, Frank was admitted to hospital with a prolonged episode of painless jaundice.The textbooks explain that jaundice is always obstructive, either due to biliary duct blockage from gallstones or compression of smaller bile ducts due to tumours, cirrhosis, or catarrh [inflammation] (Ashdown, 1929).Cirrhosis is caused by alcohol and occurs in people aged over 40 years (Ashdown, 1929), and catarrhal jaundice is the most common cause in younger people (Morten and Taylor, 1942).The hospital chart shows that blood pressure measurement was not a regular clinical observation at that time which further blurs the clinical picture for contemporary interpretation.Nurses at that time however would have noted the quality of the palpated pulse with "bounding" and "thready" being an unscientific and often inaccurate way of indicating high or low blood pressure respectively.Nursing care, then and now, places high emphasis on the importance of maintaining asepsis and cleanliness, but sterility standards were not as they are today.For example, in addition to the initial laparotomy it is noted that Frank received two blood transfusions, and these would have been undertaken thus: "both blood donor and recipients' skin incised, vein incised, glass cannula inserted into veins, 20ccs blood drawn from donor in a syringe and injected into patient, continue as necessary" (Ashdown, 1929, p.70).Furthermore, the bedside jejunostomy (opening an area of small bowel), however well intentioned, would not have met today's standards of an aseptic procedure.The overall risk of Frank developing sepsis during this hospital admission is high and whilst he was apyrexial, I wonder if the more recently described phenomenon of "cold" sepsis may also have contributed to the outcome (Rumbus, 2017).
A number of infectious and hepatic causes of jaundice have been discussed and discounted.However, I am drawn back to the letter from Lettice reporting that not just the liver, but kidneys too, were in a "frightful condition".A case study by Zang et al ( 2020) report the story of a man with polycystic liver and kidney disease (a rare genetic condition).The resultant obstructive jaundice could be due to the cysts squeezing the bile ducts, but alternatively could be due to the bile duct malformation that can occur in this condition.Any intra-hepatic irregularities may not be easily visualised via a laparotomy and there is no postmortem histopathology report.
The exact cause of Frank's jaundice may never be known.However, it is easy to agree with the authors that the surgical interventions hastened his death.
Turning to the philosophical section of this paper, Frank's explanations about partial beliefs and probability are very clearly aligned with contemporary health care decision making.The saying (appropriated from opera) that " it's not over until the histopathologist has sung" certainly follows the maxim that subjective belief is refined through experience, experimentation, and measurement.Additionally, the starting point of subjectivity and progressive refinement is reminiscent of the retroductive form of reasoning proposed by Bhaskar (2016, p.3), this being a disciplined imaginative process whereby the researcher develops the causes or unseen generative mechanisms which if existed would explain the outcomes observed.
There is a growing appetite amongst healthcare researchers, particularly nurses and other nonmedical allied healthcare professionals, to conduct mixed methods research underpinned by pragmatism.Frank's philosophical position can certainly contribute to academic discussions in this field.With regards to what could be learnt from this case study for nurses, apart from the importance of documentation, the need to deliver care grounded in evidence remains paramount and our professions' contemporary role as patients' advocate supports this action.Is the background of the case's history and progression described in sufficient detail?Partly

Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Partly
Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?Yes Is the case presented with sufficient detail to be useful for other practitioners?Yes Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Liver disease, health inequalities, mixed methods research I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.
Department of Philosophy, Rochester Institute of Technology, Rochester, New York, USA This account of Frank Ramsey's last days is a thought-provoking combination of history, medicine, philosophy, tragedy and mystery.My comments have little to do with substance-the article is clearly written, carefully researched and argued, and peels back the layers of a sad episode in 20th century intellectual history-and more to do with some of the thoughts it provokes.While Ramsey might not be thought of primarily as a philosopher, his death is another instance of philosophers meeting untimely and tragic ends.This all started with Socrates (hemlock), continued through Descartes (supposedly the victim of a pre-dawn teaching schedule), and happened more recently to Moritz Schlick (murdered by a student whom the Nazis later released from prison) and Janina Hosiasson-Lindenbaum (arrested by the Gestapo and executed in 1942).The list goes on.
As Cheryl Misak describes in her 2020 biography Frank Ramsey: A Sheer Excess of Powers, Ramsey's ideas had and continue to have an impact across a variety of fields: mathematics, economics, philosophy, and computer science, to name a few.Perhaps he was lucky or just very good, but he seemed to have had a knack for being in the right place at the right time, rubbing shoulders and carrying on conversations with influential intellectuals and public figures of the post-WWI era.Or: as this article shows, he was lucky until he wasn't, dying at-by our contemporary standards at least-the shockingly young age of 26.
Ramsey was super-smart but his early death is surely part of his mystique.There's a sense of doom and tragedy that hangs over his story.It's refreshing that the authors approach his death not merely as a depressing piece of trivia but as an opportunity to draw connections to Ramsey's own views about decision-making under uncertain conditions.That's where the story also becomes a mystery: as their title puts it, "what-or who-killed Frank Ramsey?" Was it Leptospirosis?Primary sclerosing cholangitis?Or was it a well-intentioned but ultimately fatal surgical intervention?
We might also wonder why and whether we should care about the cause of Ramsey's death.I don't mean this to sound flippant: I think there are some interesting philosophical questions in the vicinity that are worth considering.For one thing, the authors note that "it is unlikely that we or our successors will arrive at a definitive truth about the question: what was the illness that led to Ramsey's death?But such a definitive truth was something about which Ramsey gave us reasons to be suspicious."I'm not sure if this means that definitive truths are suspect in general or merely that, in this particular case, the definitive truth is out of reach.I'm also not sure whether to put the stress on definitive or truth.If the former this would suggest that we can arrive at the truth but without the certainty to call it "definitive"; if the latter, this would suggest that there is nothing that we could call the "truth" about Ramsey's illness.I take the authors' point to be that there are factors in this particular case that put the definitive truth out of reach: most likely a combination of historical distance, missing paperwork, and the uncertainty that, as they point out, "must permeate medicine."Moreover, I don't think they are denying that there is a truth about Ramsey's illness.Rather, Ramsey's illness seems to be an example of what C.S. Peirce (one of Ramsey's influences) called a "buried secret.""Buried secrets" pose a problem for Peirce (and maybe for Ramsey too) because he defined truth in terms of what would stand up to unlimited levels of scrutiny.For example, to say that it is true that Ramsey was born in 1903 is just a more efficient way of saying that this claim would be supported by the evidence no matter how long or how hard one looked (by consulting Wikipedia, finding his original birth certificate, digging up obituaries, reading the biography…).The problem of buried secrets, then, is that if a claim resists scrutiny-perhaps because it is about the distant past or about trivial matters that no one bothered to record-then on Peirce's account it would seem to be neither true nor false.That will strike a lot of people as an obvious mistake because we tend to think of truth and knowability as different properties: a claim can be unknowable but still be true.Peirce's own response to this problem wasn't always clear but he did claim that "followers of science are animated by a cheerful hope" that the truth can always be unearthed and Ramsey seemed to agree with this, at least with respect to the types of counterfactuals discussed in this article.While we can't rule out the possibility of buried secrets, "followers of science" are bound to assume that there's no secret that cannot be revealed given enough time, energy, and ingenuity.This would apply to the Ramsey's final illness as well: even if the definitive truth is out of reach we hope there's still a truth to be discovered.
So, why do we (or some of us) care to discover the truth about Ramsey's illness and death?We don't care for any of the typical and familiar reasons: Ramsey isn't a personal friend or relative, there is no living person to be held responsible or punished, and understanding his cause of death won't have any direct effect on current clinical practice.Lots of people-lots of people-die too soon, and under much worse circumstances.And, yet, we care about Ramsey.
The reason we care about Ramsey and his illness is connected to why we care about the truth.If we're pragmatists like Ramsey then we don't care about the truth merely for its own sake.Fundamentally, we care about the truth because we care about getting things right, and we care about getting things right because we want to achieve our goals.One goal of medical professionals is to uphold the Hippocratic Oath: do no harm.The authors of this article argue convincingly that Ramsey died because a surgeon just couldn't help himself.He felt compelled to operate and did harm as a result.Perhaps Ramsey's medical team did the best they could.That's what makes this a tragedy.
Hope plays a role here as well.We hope that we can do better than those who came before.We hope that when we get things right we really get them right.But what reason is there for this hope?Why prefer hope over despair?It's here that Ramsey himself has something to add: I find, just now at least, the world a pleasant and exciting place.and a wide network of experts, the authors illustrate how much judgment plays a role in ruling out each of what come across to this reader (and seemingly to the authors and their colleagues) as reasonable alternatives.Judgment by clinicians seems unavoidable in clinical decision making.The authors imply enthusiasm about the benefits of surgery could have played a role in the judgment of Ramsey's physicians and surgeon and that perhaps "they did not fully factor in the possibility that surgery would have a severely negative impact on the patient's trajectory", or rather, they misjudged the risks.This point raises a reasonable explanation for how Ramsey could end up in surgery, but it is conjecture.For example, it is possible that his surgeon had a good estimate of the risk and appreciated the possibility of there being no stone present, but still felt that on the balance of probabilities (or something akin to that in the surgeon's belief based on what was known at the time prior to surgery and the clinical narrative he and the other clinicians established), surgery was the best way forward.It may be that many surgeons of the day (or even today) put in his shoes would have settled on the same decision.If so, would it be fair to say the surgeon is responsible for Ramsey's death (which is different than saying the surgery is the cause of his death)?I raise this issue mindful that cases that are subject to clinical malpractice suits may share features with the one presented in the manuscript.What could be learned from the analysis of the Ramsey case (and his philosophy) that is relevant to how we deal with malpractice suits in courts of law?
The second issue I would like to explore is the tension between the "subjective component of clinical expertise and wisdom" and the "algorithm" or actuarial reasoning from formally collected data.The authors state that "all the clinical decision rules in the world cannot substitute for the subjective component of clinical expertise and wisdom", but also state that "physicians should not play their hunches as a substitute for following the algorithm".These are two extremes, and it is fear of following bad hunches that to me seems to be a driving factor in and the appeal (to many) of evidence based medicine thinking.What does the Ramsey case tell us about the balance between clinical hunches (e.g, which might be used to build an initial set of differential diagnoses) and clinical decision rules?Is there anything in this case or his philosophy that leads to understanding what is an appropriate balance?Were the clinicians in the Ramsey case playing their hunches or were they making reasonable and calculated decisions based on what were their algorithms for practice?Was it their algorithms that let them down or was it that they did not pay enough attention to them?What could they have done better?
Overall, I very much enjoyed reading the manuscript and applaud the authors for taking on this case.I feel that the study highlights an important activity in clinical practice, i.e., reflection on practice.That reflection need not be about one's own practice, as something can be learned from a review of any clinical case, both challenging and seemingly mundane.I am encouraged that such review and reflection is done to some extent in many clinical environments, in particular academic hospitals, in various forms, such as weekly clinical or academic rounds, safety committees for clinical errors, near misses, or sentinel events, etc.I am even more encouraged that the clinician authors engaged in a deep dive of a historical case.Thus, this case is not a purely academic exercise or should not only be of interest to philosophers and historians.It provides real analysis of clinical practice and raises important considerations about reasoning that is highly relevant for both clinical learners and practicing clinicians.
Is the background of the case's history and progression described in sufficient detail?Yes

Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Yes
Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?Yes Is the case presented with sufficient detail to be useful for other practitioners?Yes Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Health Services Research/Epidemiology, History and Philosophy of Science I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.
My report is not so much a peer review as a commentary, and a rather self-indulgent one at that.I want to engage with some of the authors' arguments and premises in ways that are not critiques of the paper itself.They are just thoughts that it stimulated (debatable thoughts maybe, but isn't that the point of philosophy?), which the authors and readers might like to think about and perhaps take account of, even though they relate to what anyone familiar with my own work will recognise as Hobby Horses.(Does that count as a minor conflict of interest?) I have to confess to my own priors as I began to read the article.Having many years ago been a (Wellcome-funded) medical historian, I groaned inwardly at the prospect of reading an historical diagnosis.When one maintains, as I did back then and still do now (Hobby Horse #1), that our concepts of disease are social constructs, and that all our observations are theory laden, then surely the idea of retrospectively using our modern constructs to interpret past observations is doomed.We have no choice but to work with the findings of doctors from a different world, who had different theoretical lenses, different norms of practice, different available diagnostic resources and different treatment choices.They were answering questions that literally only made sense in their own context.All of that makes it impossible to achieve a simple "real truth out there" from some objective perspective -to find out "what really happened".I long ago argued that if we want to know, for example, what asthma was like in the C18 th , e.g.whether it had the same characteristics as now, then however hard we try (and I did), we find ourselves unable to do so.(A form of what I labelled "historical paralysis" (Gabbay 1982)).And even when we think we have indeed reconstructed some past disease, we have almost certainly done so by applying diagnostic criteria based on our modern understanding of patho-physiology, for example, to give that pastperceived/ long-ago-constructed reality a (modern) name, a modern construction -solving a problem that is now re-framed in modern terms.In doing so we have inevitably distorted what happened.Hence I usually ask "What on earth is the point of doing that?Is it telling us something about the past or about ourselves?"All of which explains why I thought there would be precious little point in reading a post-mortem inquiry into a death caused so long ago.(Moreover -and this is a separate concern -how would we know that we, the clever modern diagnosticians with all our modern knowledge, have finally got the answer right?Who is to say that in 100 years' time, when we are all history, someone won't be writing a paper savouring the irony that the authors of this article hadn't recognised a clear case of Foster-Vinetz syndrome, first described back in 2027?) However, these authors have shown me that there can indeed be a point to such an exercise.On two levels.First, reading the early sections was ... fun!It really got my diagnostic juices going (they'd dried up about 40 years ago when I left clinical medicine behind).The exposition of the differential diagnoses and their pros and cons is a great read and I imagine that practising clinicians who read these pages would learn much from it.Second, in the later sections of the paper, this case-history is indeed being explicitly used to solve a relevant C21 st problem -not a long-forgotten clinical one, but a current philosophical one.The authors use their findings in a very intelligent and illuminating way by analysing the thinking underpinning the medical decisions and actions they describe.Even just to do that would have been an ingenious stroke, but to do it using the philosophical framework developed by the unfortunate patient?That's terrific!Probably unique (but then, so was Frank Ramsay).
I don't feel qualified to comment on the exposition of Ramsay's philosophy, but the way the authors approach the clinical-reasoning side of the story is a great read.However, (and here comes Hobby Horse #2), I think it is also largely a misleading fiction.The hypothetico-deductive line of enquiry, the objective solution of a logical puzzle, complete with careful analysis of probabilities and priors, of likelihood ratios and receiver-operator curves… Really?In an overstretched hospital or an overworked GP's surgery?No doctor would survive more than a day behaving that way -and more to the point, neither would many of the patients she never got round to seeing because she was being so rigorously systematic about the few patients that she did ponder at such length.If you want to understand how doctors really think, you'll need to go beyond an analysis such as this.At least the authors claim only that doctors these days are "taught" and "encouraged" to compute prior and posterior probabilities based on RCTs, to quantify the likelihood ratios, and so on.Perhaps they covertly recognise that it's not often that practitioners actually do all that stuff.What's described in this paper is the idealised, rationalised version of how doctors think -or should think -not how they normally do think.Even if they wanted to, or remembered how to, most clinicians aren't in any position to indulge in the luxury of such elaborately logical thinking.Nor can they get by (for long!) relying as suggested in the paper on shortcuts and heuristics, on maxims and rules of thumb -which can be error strewn.Nor is their thinking just a Gestalt that (magically?) emerges, as the authors describe it, from a "potpourri".What clinicians do in practice is both more complicated and more simple than that.In reality, practitioners' thinking embodies aspects of all the above -and a lot more besides.From what we have observed in a series of ethnographic studies, practitioners make their decisions thanks to their clinical mindlines.
Clinical mindlines, are "internalised, collectively reinforced and often tacit guidelines that are informed by clinicians' training, by their own and each other's experience, by their interactions with their role sets, by their reading, by the way they have learnt to handle the conflicting demands, by their understanding of local circumstances and systems, and by a host of other sources" (Gabbay and le May 2011, page 44).They are not lengthy logical thought processes, nor lazy shortcuts, nor deft 'intuition', but a deeply developed embodiment of many types of accumulated knowledge-in-practice-in-context that enables good practitioners to make astonishingly fast, efficient, and flexible decisions.
Moreover, as our ethnographies showed, a crucial part of the mindlines model is the way in which clinicians consult colleagues whose opinions they trust (Gabbay and le May 2016).Sometimes they do that in addition to going through the literature, sometimes instead of doing so.It's clear that even the authors of this article didn't (just) scour everything worthwhile that's been written about sclerosing cholangitis or leptospirosis or whatever.They talked or corresponded about the problem as a "team", doubtless eliciting and checking out each other's assessments, judgements, and experience; they consulted colleagues like Albert Ko and Joseph Vinetz.And that is exactly what most clinicians do, for mindlines are also a collective phenomenon.(In all probability, Colley and his colleagues would have acted similarly in the doctors' dining room, on the ward round, in theatre, in the library, and striding together down the long hospital corridors.) Andrée le May and I would argue that clinical mindlines are a highly sophisticated and hard-won way of making rapid decisions while taking account of a myriad different kinds of knowledge accumulated over a lifetime of (social, interactive) knowledge-gathering and experience -several lifetimes if you include the colleagues who contribute their experience and expertise to an individual's mindlines.Mindlines are a kind of collective professional capital that should not be ignored in favour of unrealistic exhortations to rigorous, time-consuming, formal assessment of probabilistic, trials-based information that never quite fits the kind of individual clinical problem that Ramsay posed.The hyper-rational thinking described in this article is occasionally necessary.But is almost certainly never used alone to manage a condition or patient such as this.Let's not pretend it is, and let's celebrate (and try to understand better, and hence improve) the mindlinesmediated, socially-constructed thinking that really shapes most clinical decisions.
The irony is that a decade ago now, in her endorsement on the cover of the book in which Andrée le May and I elaborated the concept of clinical mindlines, Trisha Greenhalgh was kind enough to call it "one of the most important publications about clinical practice and evidence-based medicine to appear in the last 20 years".She and her present co-authors may, therefore, wish to consider at least a nod in the direction of mindlines as they analyse the decision-making processes in such a challenging case as Ramsay's.
Well, I promised a self-indulgent commentary, and I'm sorry for that.But I hope that by trotting out my two main Hobby Horses I may have encouraged the authors and readers of this absorbing article to take the opportunity for a bit of a reality check.

Figure 1 .
Figure 1.Frank Ramsey's hospital chart (reproduced with permission from surviving relatives) and Caldicott Guardian at Guy's and St Thomas's NHS Trust.

References 1 .
Asthma attacked?Tactics for the reconstruction of a disease concept, In: P. Wright.2. Gabbay J, le May A: Practice-based Evidence for Healthcare.2010.Publisher Full Text 3. Gabbay J, le May A: Mindlines: making sense of evidence in practice.British Journal of General Practice.2016; 66 (649): 402-403 Publisher Full Text Is the background of the case's history and progression described in sufficient detail?Yes Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes?Yes Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?YesIs the case presented with sufficient detail to be useful for other practitioners?PartlyCompeting Interests: I know Trish Greenhalgh personally to the extent that our professional paths have often crossed, for example reviewing each other's drafts and having intermittent conversations.This has not impacted the impartiality of my review Reviewer Expertise: Knowledge mobilisation I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

provided of any physical examination and diagnostic tests, treatment given and outcomes? Yes Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Yes Is the case presented with sufficient detail to be useful for other practitioners? Yes Competing Interests:
You may find it depressing; I am sorry for you, and you despise me.But I have reason and you have none; you would only have a reason for despising me if your feeling corresponded to the fact in a way mine didn't.But neither can correspond to the fact.The fact is not in itself good or bad; it is just that it thrills me but depresses you.On the other hand, I pity you with reason, because it is pleasanter to be thrilled than to be depressed, and not merely pleasanter but better for all one's activities.(1990:249-250)Nocompeting interests were disclosed.